Prophy vs. perio maintenance

Dear Dianne:

What is the best way to explain the difference between a prophy and a periodontal maintenance visit? I'm having a hard time developing good verbiage, and I think my patients do not really perceive the difference. Thanks for your help.

Norma in California

Dear Norma:

There is widespread confusion in this area. I believe the solution lies in your own understanding of the difference between a prophy and a periodontal maintenance appointment.

First, let's establish that prophys are for healthy mouths. The CDT-3 book of dental codes published by the ADA defines a prophy: "Dental Prophylaxis - D1110 - A dental prophylaxis performed on transitional or permanent dentition which includes scaling and polishing procedures to remove coronal plaque, calculus, and stains."

The key word here is "coronal." All hygienists do subgingival scaling on many patients who have not been classified as periodontal patients. The reality is that patients who accumulate supragingival calculus deposits invariably will have subgingival deposits as well. However, in the strictest sense of the definition, a prophy is a simple procedure on a patient that does not have significant subgingival deposits or periodontal pocketing. The typical prophy patient comes every six months, exhibits excellent homecare, has healthy gingival tissues, does not bleed on gentle probing, and has no pockets over 4mm.

Now let's examine the definition of periodontal scaling. This code, D4341, is defined as follows: "This procedure involves instrumentation of the crown and root surfaces of the teeth to remove deposits and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs."

Periodontal procedures are, for the most part, subgingival in nature. Periodontal scaling requires more skill and expertise than prophylaxis procedures. Patients with periodontal disease, either active or inactive, bear the scars of the disease process - such as bone loss and pocketing - which is rarely generalized throughout the mouth. Periodontal disease is a bacterial and/or viral proliferation of pathogens that overwhelms the host defenses and spurs the host's own immune system to initiate a breakdown of supporting tooth structures. Periodontal disease also is episodic in nature. Destructive episodes can occur unbeknownst to the patient and can be triggered by stress, disease, or other systemic problems.

We also know that periodontal disease is not a "curable" disease, but it is controllable in most patients. Therefore, when a patient has experienced periodontal disease in the past, we must be ever-vigilant to monitor for signs of active disease long after the disease has been brought under control through good periodontal therapy.

Now, let's discuss the code D4910, periodontal maintenance procedures (following active therapy). The definition from CDT-3 is: "This procedure is for patients who have completed periodontal treatment (surgical and/or nonsurgical periodontal therapies exclusive of D4355) and includes removal of the bacterial flora from crevicular and pocket areas, scaling and polishing of the teeth, periodontal evaluation, and a review of the patient's plaque control efficiency. Typically, an interval of three months between appointments results in an effective treatment schedule, but this can vary depending upon the clinical judgment of the dentist. When new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered. Periodic maintenance treatment following periodontal therapy is not synonymous with a prophylaxis."

According to this definition, true periodontal maintenance procedures follow active periodontal therapy such as root planing and scaling. The goal of active therapy is to remove as much subgingival debris as possible and disrupt/destroy the bacterial proliferation. The goal in periodontal maintenance is to debride the sulcular areas of attached and non-attached plaque pathogens.

If you have been thorough in your periodontal scalings, you would not expect to find much calculus at a three-month interval. Of course, there are exceptions to every rule, and there are some patients that produce significant new calculus in three months. However, that will usually be supragingival, not subgingival. I recommend that, after a patient has been through active periodontal therapy, all their subsequent recare visits be coded 4910, periodontal maintenance. The actual fee may be adjusted up or down, depending on the amount of time required and severity of the disease.

It is necessary for you to understand in your own mind that periodontal maintenance is different from a regular prophy because you are controlling disease with periodontal maintenance.

In addition, you should be using thin ultrasonic inserts on low power for at least 75 percent of the scaling in a periodontal maintenance visit. Ultrasonics are more effective at debriding pathogens than hand scaling, largely because of the lavage (either water or medicament) and the acoustic turbulence created by the tip. It is advisable to make several trips around the mouth, making sure you visit and revisit all sulcular areas.

Dental hygienists teach patients good plaque control measures. However, these measures are largely supragingival. Supragingival plaque control does little to control a subgingival disease. It is our professional care that helps our patients attain and maintain good oral health. Don't misunderstand - I'm not discounting the value of good plaque control measures. However, as professionals, we are skilled in accessing deep sulcular areas that the patient simply cannot reach.

Regarding the value of periodontal maintenance, the World Workshop in Clinical Periodontics made these statements: "Mainte-nance visits on a regular basis seem to be more important in retention of teeth than either the type of active treatment accomplished or oral hygiene practices," and "…supportive maintenance care remains the most dependable measure for disease control in the treated periodontal patient."

Now, how can we relay that to the patient in a nontechnical way that will help him or her understand the value of three-month visits for at least a year following active therapy? A sample conversation that you may want to adapt to your situation is within the box on this page.

When your patients understand the reasons behind frequent professional care, they are more apt to comply. It is for their good, not the financial good of the practice. If you have developed a close professional rapport with your patient through the course of the therapy, he or she will trust your recommendations.

In some dental practices, a periodontal maintenance visit looks no different from a prophy. That is unfortunate, because the two procedures should be different. Furthermore, if you understand the difference, your treatment protocol will be different and the patient will perceive a difference.

Dianne

See you in three months…

Hygienist: Mrs. Jones, we have certainly come a long way in getting your gums healthy again. You and I together have made this happen. However, we are not completely out of the woods yet. The next 12 months are very critical to making continued progress. Periodontal disease is not curable, but it is controllable, similar to diabetes. We have been successful in bringing those bad bugs that are causing your disease under control. However, please be aware that the pathogens can multiply and rise up again causing more tissue destruction and bone loss. We will need to monitor you closely over the next 12 months to make sure you remain stable and control the new growth of bacteria. From our experience in treating many other patients with periodontal disease, we have learned that maintenance visits should be no more than three months apart.

Patient: After a year, then what?

Hygienist: If you continue to improve and your condition stabilizes, we may be able to extend the amount of time between visits. That certainly will be our goal. We will be able to evaluate that better after a year. Over the next year, we hope that our professional care coupled with your good homecare will allow your host immunity to become strong enough to keep the destructive germs under control.

Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Lexington, N.C. To contact Glasscoe for speaking or consulting, call (336) 472-3515, fax (336) 472-5567, or email dglasscoe@northstate.net. Visit her Web site at www.profession aldentalmgmt.com.

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